Progress with the Learning Health System 2.0: a rapid review of Learning Health Systems' responses to pandemics and climate change.

BACKGROUND: Pandemics and climate change each challenge health systems through increasing numbers and new types of patients. To adapt to these challenges, leading health systems have embraced a Learning Health System (LHS) approach, aiming to increase the efficiency with which data is translated into actionable knowledge. This rapid review sought to determine how these health systems have used LHS frameworks to both address the challenges posed by the COVID-19 pandemic and climate change, and to prepare for future disturbances, and thus transition towards the LHS2.0. METHODS: Three databases (Embase, Scopus, and PubMed) were searched for peer-reviewed literature published in English in the five years to March 2023. Publications were included if they described a real-world LHS's response to one or more of the following: the COVID-19 pandemic, future pandemics, current climate events, future climate change events. Data were extracted and thematically analyzed using the five dimensions of the Institute of Medicine/Zurynski-Braithwaite's LHS framework: Science and Informatics, Patient-Clinician Partnerships, Continuous Learning Culture, Incentives, and Structure and Governance. RESULTS: The search yielded 182 unique publications, four of which reported on LHSs and climate change. Backward citation tracking yielded 13 additional pandemic-related publications. None of the climate change-related papers met the inclusion criteria. Thirty-two publications were included after full-text review. Most were case studies (n = 12, 38%), narrative descriptions (n = 9, 28%) or empirical studies (n = 9, 28%). Science and Informatics (n = 31, 97%), Continuous Learning Culture (n = 26, 81%), Structure and Governance (n = 23, 72%) were the most frequently discussed LHS dimensions. Incentives (n = 21, 66%) and Patient-Clinician Partnerships (n = 18, 56%) received less attention. Twenty-nine papers (91%) discussed benefits or opportunities created by pandemics to furthering the development of an LHS, compared to 22 papers (69%) that discussed challenges. CONCLUSIONS: An LHS 2.0 approach appears well-suited to responding to the rapidly changing and uncertain conditions of a pandemic, and, by extension, to preparing health systems for the effects of climate change. LHSs that embrace a continuous learning culture can inform patient care, public policy, and public messaging, and those that wisely use IT systems for decision-making can more readily enact surveillance systems for future pandemics and climate change-related events. TRIAL REGISTRATION: PROSPERO pre-registration: CRD42023408896.

Benchmarking the university campus food environment and exploring student perspectives about food insecurity and healthy eating: a case study from Australia.

OBJECTIVE: To benchmark the university food environment and explore students' experiences with food insecurity and healthy eating in order to inform interventions to improve access and affordability of healthy foods for university students. DESIGN: A food environment audit was conducted on the university campus using the Uni-Food tool from April to May 2022 and was comprised of three main components, university systems and governance, campus facilities and environment, and food retail outlets. A qualitative study design was also used to conduct focus groups and semi-structured interviews with students to explore key themes regarding their experiences with food insecurity and healthy eating. SETTING: Macquarie University, Australia. PARTICIPANTS: For the food environment audit 24 retail outlets on campus and for the qualitative component 29 domestic and international students enrolled at Macquarie University. RESULTS: The university only scored 27% in total for all components in the food environment audit. The results showed the need for better governance and leadership of the food environment. The qualitative component suggested that the main barriers to accessing healthy foods were related to availability, pricing, and knowledge of healthy foods. Future intervention ideas included free fruits and vegetables, food relief, discounts, improved self-catering facilities, education, and increased healthy food outlets. CONCLUSIONS: Improving governance measures related to healthy eating on campus are a core priority to strengthen the food environment and students identified pricing and availability as key issues. These findings will inform effective and feasible interventions to improve food security and healthy eating on campus.

Exploring reasons for high levels of food insecurity and low fruit and vegetable consumption among university students post-COVID-19.

High rates of food insecurity and low consumption of fruit and vegetables among university students have been observed prior to the COVID-19 pandemic and intensified during the pandemic. This study aimed to investigate food insecurity among university students and its associations with sociodemographic factors, fruit and vegetable consumption behaviours, and preferred campus programs to address these issues. A convenience sample of 237 Australian university students completed a cross-sectional online survey from October to December 2022. Food insecurity was assessed using the 10-item US Adult Food Security Module, applying the Canadian classification scheme. Sociodemographic variables, fruit and vegetable consumption behaviours, and perceptions of fruit and vegetable access and their affordability were included in the survey. Students were also asked to select the most suitable program(s) and provide reasons for their choice using open-ended questions. Approximately half of respondents (46.4%) were identified as food insecure. The proportion of students meeting the recommended intake of vegetables as specified in the Australian Dietary Guidelines was very low (5.1%) compared with fruit (46.2%). Low fruit consumption was significantly associated with food insecurity (OR = 1.81; 95%CI 1.03, 3.18, p = 0.038). Factors such as the perceived lower accessibility and higher price of fruit and vegetables were significantly associated with higher odds of food insecurity. In terms of potential programs, a free fruit and vegetable campaign was the most popular program, with affordability and physical access being the most frequently cited reasons. These findings suggest that food insecurity is associated with low fruit and vegetable consumption in university students. Therefore, transforming campus food environments and developing food policies at the university level must be considered to address food and nutrition security in university students.

Bolstering health systems to cope with the impacts of climate change events: A review of the evidence on workforce planning, upskilling, and capacity building.

BACKGROUND: As global CO2 emissions continue to rise and the 'era of global boiling' takes hold, the health workforce must cope with the challenge of providing care to increasing numbers of patients affected by climate change-related events (e.g., hurricanes, wildfires, floods). In this review, we describe the impacts of these events on the health workforce, and strategies responding to these challenges. METHODS: This rapid systematic review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses and a registered protocol (PROSPERO CRD42023433610). Eight databases were searched in May 2022 and again in June 2023. Empirical studies discussing climate change and workforce policy, planning, preparedness, and capacity were included. Inductive thematic analysis of extracted data was conducted. RESULTS: From the 60 included studies, two categories emerged: the impacts of climate events on the health workforce (n = 39), and workforce responses to and preparations for climate events (n = 58). Thirty-seven studies reported on both categories. Four impact themes were identified: absenteeism, psychological impacts, system breakdown, and unsafe working conditions; and six responses and preparations themes: training/skill development, workforce capacity planning, interdisciplinary collaboration, role flexibility, role incentivisation, and psychological support. CONCLUSION: This review provides an overview of some of the deleterious impacts of climate events on the health workforce, as well as potential strategies for the health workforce to prepare or respond to climate events. Future studies should assess the implementation and effectiveness of these strategies to ensure a continuously improving healthcare system, and a well-supported health workforce.

Fruit and vegetable consumption and depression symptoms in young women: results from 1973 to 1978 cohort of the Australian Longitudinal Study on Women's Health.

PURPOSE: Growing evidence suggests that specific food groups may play an important role in improving mental health. However, very few studies explored the association between individual dietary factors and depression symptoms by following a large cohort of individuals over a long period. We examined the differential effects of fruit and vegetables in relation to depression symptoms over a 15-year follow-up period in the 1973-78 cohort of the Australian Longitudinal Study on Women's Health. METHODS: Fruit and vegetable consumption was assessed using short questions. The Center for Epidemiologic Studies Depression-10 scale with a cut off ≥ 10 indicated depressive symptoms. Multiple imputations with generalised estimating equations models were performed to estimate odds ratio of depression symptoms according to fruit and vegetable consumption. RESULTS: A total of 4241 participants with a mean age of 27.6 (SD 1.45) years at baseline were followed up at five surveys (2003-2018). Fruit and vegetable intake (≥ 2 servings) was cross-sectionally associated with lower odds of depressive symptoms. In longitudinal analysis, a higher intake of fruit (≥ 4 servings) and vegetable (≥ 5 servings) was consistently associated with lower odds of depressive symptoms, with a 25% lower odds (OR 0.75; 95% CI 0.57, 0.97; p = 0.031) and a 19% lower odds (OR 0.81; 95% CI 0.70, 0.94; p = 0.007) than consuming one serve or less fruit and vegetable, respectively. CONCLUSION: These results suggest that a higher intake of fruit and vegetables was associated with a lower risk of depression symptoms over 15 years from a population-based prospective study of Australian women.

The prevalence of psychological distress and its associated sociodemographic factors in the Australian adults aged 18-64 years during COVID-19: Data from the Australian National Health Survey.

OBJECTIVE: COVID-19 significantly contributed to an increase in psychological distress and may have disproportionally impacted certain sociodemographic groups. This study aimed to assess the prevalence of psychological distress among Australian adults aged 18-64 years and identify sociodemographic factors associated with psychological distress during the COVID-19 pandemic. METHODS: Secondary analyses were conducted using data from the National Health Survey 2020-21 to calculate weighted national estimates of the prevalence of psychological distress using the Kessler Psychological Distress scale (K10). The association between sociodemographic factors and psychological distress was analysed using multivariable logistic regression, with adjustments for complex survey design. RESULTS: The average of K10 score was 16.94, with a prevalence of combined high/very high distress reported at 21.13 % among Australian adults. Young women aged 18-25 reported the highest average scores (M = 20.44) across all sex and age groups. Risk factors associated with psychological distress included lower personal income, marital status (never married; widowed/divorced/separated) and being 'born in Australia'. Protective factors included homeownership and having children in the household. Additionally, among women, being aged ≥56 was significantly associated with lower odds of psychological distress. LIMITATIONS: Data collection relied on self-completed online form, and a cross-sectional design limits the inference of a causal relationship. DISCUSSION: During COVID-19 pandemic, lower personal income and being female have consistently been identified as risk factors for psychological distress. Targeted and tailored interventions based on age, sex and disadvantage are warranted, particularly focusing on younger women, to alleviate the adverse effect of the pandemic on the population's mental health.

Food Choices, Sustainability and Australian Native Foods: Perceptions among University Students.

(1) Background: Urgent changes in our food choices are needed for more sustainable, resilient and equitable food systems. Australian native plant-based foods have both environmental and health benefits. Including these foods in our diet may reduce both the risk of chronic diseases and the impact of climate change. This study explored the perceptions and attitudes towards food choices, sustainability and Australian native plant-based food among university students. (2) Methods: A cross-sectional online survey was completed by 212 university students in Australia from October to December 2022. Questions included information about sociodemographic characteristics, food choices, Australian native foods and the impact on sustainability. Logistic regression was used for analyses. (3) Results: Most participants recognised the impact of food choices on sustainability. There was a significant association between recognition of the impact of food choices on sustainability and the environmental and nutritional benefits of Australian native foods (OR = 2.89, 95% CI 1.29, 6.46, p = 0.010). Students who were familiar with or had tried Australian native plant-based foods were significantly more likely to recognise their environmental and nutritional benefits (p < 0.001). (4) Conclusions: Students who recognise the impact of food choices on sustainability and the benefits of Australian native foods are more likely to include native foods in their diet. More studies are needed to investigate the specific native foods consumed and the barriers and facilitators to the intake of these foods.

Contributions of digital technologies for resilience capacity in a type 1 diabetes transition clinic: A qualitative study.

A type 1 diabetes (T1D) transition clinic in Sydney, Australia, provides age specific care for young adults (aged 16-25 years) and for adults (aged 21 years and above), and has reported improved clinical outcomes post transition to adult care over a 21-year period. This study investigated the contribution of digital technology to long-term resilient capacity of the clinic. Clinic observations and interviews with eight providers and 17 young adults were conducted. Using a framework to analyze resilient capacity in healthcare, seven strong themes emerged from the data: Leadership, Involvement, Communication, Coordination, Risk Awareness, Competence and Alignment with three themes, Structure, Learning and Facilitators also supported. Patient service adaptations included offering out of hours appointment times and telehealth to accommodate young adults' availability. This study provides evidence for the important role that digital technologies contribute to a system of care with capacity for resilience. Our findings contribute to the understanding of the factors needed to support young adults with T1D and may be valuable to inform models of care for young adults living with other chronic health conditions.

Navigating Neighbourhood Opposition and Climate Change: Feasibility and Acceptability of a Play Street Pilot in Sydney, Australia.

BACKGROUND: Play Streets are community-led initiatives that provide opportunities for outdoor play and recreation when parks or other facilities may not be easily accessible. This pragmatic evaluation aims to determine the feasibility and acceptability of a pilot Play Street in Inner West Sydney. METHODS: We used a post-only mixed methods design. Brief intercept surveys with pilot Play Street visitors assessed their reasons for attending the event and perceptions thereof. Semi-structured interviews explored stakeholders' experiences related to planning and implementing Play Streets. RESULTS: Approximately 60 adults and children attended the pilot Play Street. The majority of survey respondents (n = 32) were female, aged 35-54, lived in the Play Street's postcode, and visited in groups consisting of adults and children. Overall respondents rated the pilot positively in enjoyment (100%), safety (97%), and organisation (81%), although there were significant differences between certain demographic subgroups in the perception of organisation and the children's enjoyment of the pilot Play Street. Stakeholder interviews (n = 2) highlighted the importance of community consultation and reaching compromises, noting concerns about safety and insurance costs, and emphasised the role of Council as a facilitator to help residents take ownership of Play Streets. Delays due to community concerns, poor air quality arising from bushfires, heavy rain on the event day, and COVID-19 lockdowns hindered pilot Play Street implementation and evaluation. CONCLUSION: This pilot demonstrated that Play Streets are a feasible and acceptable way to use streets as outdoor recreation spaces in Sydney's Inner West. The evaluation highlights two elements for future sustainability: managing neighbourhood opposition and adapting to climate change.

Built to last? Barriers and facilitators of healthcare program sustainability: a systematic integrative review.

OBJECTIVE: To identify barriers and facilitators associated with the sustainability of implemented and evaluated improvement programs in healthcare delivery systems. DATA SOURCES AND STUDY SETTING: Six academic databases were searched to identify relevant peer-reviewed journal articles published in English between July 2011 and June 2022. Studies were included if they reported on healthcare program sustainability and explicitly identified barriers to, and facilitators of, sustainability. STUDY DESIGN: A systematic integrative review guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Study quality was appraised using Hawker's Quality Assessment Tool. DATA COLLECTION/EXTRACTION METHODS: A team of reviewers screened eligible studies against the inclusion criteria and extracted the data independently using a purpose-designed Excel spreadsheet. Barriers and facilitators were extracted and mapped to the Integrated Sustainability Framework (ISF). Frequency counts of reported barriers/facilitators were performed across the included studies. RESULTS: Of the 124 studies included in this review, almost half utilised qualitative designs (n = 52; 41.9%) and roughly one third were conducted in the USA (n = 43; 34.7%). Few studies (n = 29; 23.4%) reported on program sustainability beyond 5 years of program implementation and only 16 of them (55.2%) defined sustainability. Factors related to the ISF categories of inner setting (n = 99; 79.8%), process (n = 99; 79.8%) and intervention characteristics (n = 72; 58.1%) were most frequently reported. Leadership/support (n = 61; 49.2%), training/support/supervision (n = 54; 43.5%) and staffing/turnover (n = 50; 40.3%) were commonly identified barriers or facilitators of sustainability across included studies. Forty-six (37.1%) studies reported on the outer setting category: funding (n = 26; 56.5%), external leadership by stakeholders (n = 16; 34.8%), and socio-political context (n = 14; 30.4%). Eight studies (6.5%) reported on discontinued programs, with factors including funding and resourcing, poor fit, limited planning, and intervention complexity contributing to discontinuation. CONCLUSIONS: This review highlights the importance of taking into consideration the inner setting, processes, intervention characteristics and outer setting factors when sustaining healthcare programs, and the need for long-term program evaluations. There is a need to apply consistent definitions and implementation frameworks across studies to strengthen evidence in this area. TRIAL REGISTRATION: https://bmjopen.bmj.com/content/7/11/e018568 .

Investigating Web-Based Nutrition Education Interventions for Promoting Sustainable and Healthy Diets in Young Adults: A Systematic Literature Review.

BACKGROUND: Our current rapidly growing food systems are imposing a heavy burden on both environmental sustainability and human health. Sustainable and healthy diets aim to promote optimal health and have a minimal environmental impact. This study aimed to critically review and synthesise the evidence on the effectiveness of web-based nutrition education interventions aiming to promote sustainable and healthy diets among young adults. METHODS: A systematic search of four databases (Medline, PsycINFO, Scopus, and Embase) was conducted in March 2021. Studies were included if they used an online platform to deliver the intervention to young adults and measured at least one aspect of sustainable and healthy diets, such as plant-based food intake, food waste, and local and seasonal produce. Of the 2991 studies, a total of 221 full-text articles were assessed for eligibility of which 22 were included in the final review. RESULTS: A majority of the studies (82%) targeted fruit and vegetable consumption, and close to a quarter of studies (23%) targeted other aspects of a sustainable and healthy diet, such as red meat intake. Only one study included multiple aspects of a sustainable and healthy diet. Program delivery outcomes reported overall positive feedback and engagement. CONCLUSION: This review suggests that web-based interventions may be effective in promoting some sustainable diet-related outcomes in young adults. However, there is a need for developing and evaluating future programs to promote sustainable diets more comprehensively in order to help young adults make healthy and sustainable food choices.

Higher Prevalence of Food Insecurity and Psychological Distress among International University Students during the COVID-19 Pandemic: An Australian Perspective.

The COVID-19 pandemic and related disruptions have not only affected university students' learning and academic outcomes, but also other issues, such as food security status, mental health and employment. In Australia, international students faced additional pressures due to sudden border closures and lack of eligibility for government-provided financial support. This study explored the experiences of domestic and international university students residing in Australia during the early stages of the COVID-19 pandemic across a range of outcomes. A cross-sectional online survey was conducted between July and September 2020 at Macquarie University in Sydney, Australia. The online survey included food insecurity status, mental health (psychological distress), disruptions to study, employment and sleep. A total of 105 students (n = 66 domestic and n = 39 international) completed the survey. Respondents reported having food insecurity (41.9%) and psychological distress (52.2%, with high and very high levels), with international students reporting significantly higher food insecurity (OR = 9.86 (95% CI 3.9-24.8), p < 0.001) and psychological distress scores (t(90) = 2.68, 95% CI: 1.30 to 8.81, p = 0.009) than domestic students. About one quarter of all respondents reported disruptions to study and employment status around the time of the survey. When asked what government support should be provided for international students, 'financial aid' was the most frequently suggested form of support. This research may help governments and educational institutions design appropriate support, particularly financial and psychological, for both international and domestic university students.

Association between Fruit and Vegetable Consumption and Depression Symptoms in Young People and Adults Aged 15-45: A Systematic Review of Cohort Studies.

Higher consumption of fruit and vegetables has been associated with a lower risk of various chronic diseases including coronary heart disease, obesity, and certain cancers. Recently, fruit and vegetable intake has also been linked with mental health, including depression; however, this area is largely unexplored studies in young people and adults. This systematic review aimed to evaluate the association between fruit and vegetable intake and depressive symptoms in young people and adults aged 15-45. The review used a predefined protocol registered with International Prospective Register of Systematic Reviews (PROSPERO) database (ID no: CRD42018091642). The systematic review focused on peer-reviewed cohort studies published from 1 January 2000 to 31 August 2020 using searches of six electronic databases. The exposure was fruit and vegetable consumption analysed both separately and/or together, and the outcome was depression or depressive symptoms. Data from eligible studies were extracted according to predefined criteria and the studies were appraised using the Newcastle-Ottawa Scale (NOS) for cohort studies to evaluate for study quality and risk of bias. A total of 12 studies from seven countries were deemed eligible and included in the qualitative synthesis, one study was categorised as "very good" quality, nine studies were "good" quality, and two studies were "moderate" quality by the quality assessment based on the total score for the NOS. The majority of cohort studies support the evidence that fruit consumption is associated with decreased risk of developing depression. However, the inconsistent results were observed when the effects of vegetable consumption were analysed independently, and the effects of fruit and vegetables combined were analysed. Despite this, the evidence seems to be building that a possible association exists, and this may have implications for addressing the burden of mental illness in young people and adults aged 15-45 years. More well-designed prospective cohort studies are needed to provide more robust evidence on the relationship between fruit and vegetable intake and depression.